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Sepsis

Sepsis
A little less conversation, a little
more action please

Aims of this session


To use Surviving Sepsis guidelines as a
framework
To focus on practical interventions that
can improve outcome in the septic
patient
To encourage you to think like intensive
care doctors
To be as interactive as possible

At the end of this session you


will be able to
Define and use important terminology
Identify features of organ failure
Prioritise urgent interventions in the septic
patient
Describe an effective fluid challenge
Demonstrate how CVP can be used to
guide fluid resuscitation
Explain ScvO2 and how it can indicate
tissue dysoxia

Definitions
Systemic Inflammatory Response
Syndrome (SIRS)
Sepsis
Severe Sepsis
Septic Shock

SIRS

SIRS
2 or more of the following:
Temp >38C or <36C
HR >90 beats/min
RR >20 breaths/min or PaCO2 <4.5kPa
WBC >12,000 or <4000 cells/mm3, or
>10% immature (band) forms

Sepsis

Sepsis
SIRS in the presence of proven or
suspected infection

Severe Sepsis

Severe Sepsis
Sepsis associated with hypotension,
hypoperfusion and/or organ-dysfunction

Septic Shock

Septic Shock
Sepsis with hypotension despite
adequate fluid resuscitation
May be vasodilatory and/or
distributive shock
Include all patients on vasopressors or
inotropic support

Organ Failure

CVS
RS
Renal
Hepatic
CNS
Haematological

Prognostic effects of organ dysfunction in severe sepsis

Prevalence of hospital mortality associated with severe sepsis

Case 1
You are called to Resus to review an 78 year old female
who presented with confusion, fever and rigors.
She is unable to give a history.
Her observations on admission are 38.30c, BP 70/35
Pulse 120 RR 30

What are your thoughts?


What would you like to do next?

Case 2
A ICU nurse asks you to urgently see an elective
cardiac patient who has just arrived from theatre,
ventilated but has had no medical handover
His obs are T35.5, BP 80/50, P100, CVP 10, SpO2 99
on 40% O2

Why is this patient hypotensive?

Case 3
The A&E SpR calls to discuss the case of a 50 year old
overweight, hypertensive, diabetic female with upper
abdominal pain and shock. The surgeons have just
started an AAA repair in theatre.
Obs: T35, BP 90/40, P100, RR36, SpO2 unrecordable
What is the differential diagnosis?
What would you like to do next?

How do we manage sepsis


and septic shock?
1) Investigate and treat sepsis

Try and find and treat source


Early blood cultures
Start antibiotics asap ideally within 1 hour
and after cultures taken

2) Assess extent of end organ


hypoperfusion and improve oxygen
delivery (early goal directed therapy)

Oxygen delivery
What does it mean?

Oxygen delivery
What does it mean?

Delivery (DO2) = O2 content x cardiac


output
= ([Hb] x SpO2 x 1.34) x (HR x SV)
Oxygen content = [Hb] x SpO2 x 1.34
Cardiac output = HR x SV

Fluid Challenge
What is the difference between an infusion and a
challenge?

Fluid Challenge
What is the difference between an infusion and a
challenge?

250 to 500 ml colloid (or blood products)


500 to 1000ml Hartmanns
[NOT 5% dextrose]
As fast a possible (with pressure bag)
You at the bedside

Fluid Challenge
Aim is to improve SV (and hence CO) by increasing
preload
Frank-Starling mechanism

Markers of perfusion
What are they?

Markers of perfusion
What are they?

Clinical signs
Warm skin, conscious level, u/o

Haemodynamic variables
CVP

Bloods
Serum Lactate
ScvO2

CVP
What does it mean?

CVP
What does it mean?

Starlings Law
Estimate of LVEDV (i.e. preload)
Not always a good correlation with
volume-responsiveness
However if low strongly suggestive of
hypovolaemia

Lactate
What does it mean?

Lactate
What does it mean?

Increased production (anaerobic glycolysis)


Tissue hypoperfusion
Tissue dysoxia

Reduced metabolism
Hepatic
Renal

<1 is normal, 1-2 is a concern, >2 is bad,


>4 is very bad

ScvO2
What does it mean?

ScvO2
What does it mean?

Balance between oxygen delivery and


consumption (VO2)
Fick principle
ScvO2 = SaO2 - VO2
CO
Target > 70%

ScvO2
What can I do if its low?

ScvO2
What can I do if its low?

Delivery = [Hb] x SpO2 x 1.34 x HR x SV

ScvO2
What can I do if its low?

Delivery = [Hb] x SpO2 x 1.34 x HR x SV


Fluid optimise
Transfuse packet cells
HCt > 30%
Inotropes

Surviving Sepsis targets of


fluid resuscitation
What are they?

SBP
MAP
CVP
U/o
Lactate
ScvO2
HCt

Surviving Sepsis targets of


fluid resuscitation
What are they?

SBP > 90
MAP > 65
CVP 8 - 12
U/o > 0.5 ml/kg/hr
Lactate < 1
ScvO2 >70
HCt > 30

Further Management
What else can be done?

Further Management
What else can be done?

Low tidal volume ventilation


Steroids in septic shock
Activated Protein C
Glycaemic control
Stress ulcer prophylaxis
Thromboprophylaxis
Sedation scoring / holds etc.

Any Questions?

Take Home Message(s)


Early intervention saves lives
Send cultures immediately
Give antibiotics early (<1 hour on ICU, <3 hrs A&E)
Aggressive targeted fluid resuscitation on the spot
(early goal-directed therapy)
CVC / ScvO2 if shocked / Lactate > 4
Involve surgeons/radiologists early (source control)

At the end of this session you


are now able to
Define and use important terminology
Identify features of organ failure
Prioritise urgent interventions in the septic
patient
Describe an effective fluid challenge
Demonstrate how CVP can be used to guide
fluid resuscitation
Explain ScvO2 and how it can indicate tissue
dysoxia

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